The US Congress’s one-year reauthorisation of the President’s Emergency Plan for AIDS Relief (PEPFAR) expires on Tuesday (25 March) and there is no clarity about its future – other than that it is likely to be slashed.

The only Bill up for discussion on this date that has any connection to PEPFAR is the Reorganizing Government Act 2025, which aims to extend the authority of President Donald Trump to propose a plan to reorganise the federal government until 31 December 2026.

PEPFAR projects can continue as long as Congressional funds are allocated to them via Appropriations Acts – but that hasn’t protected those administered by the US Agency for International Development (USAID) from being terminated.

The only inkling of what a reformed and slashed PEPFAR might look like is contained in a throwaway reference to PEPFAR in a leaked plan on US foreign aid reform that is being circulated by Trump aides, as reported by Politico.  

The “blueprint” proposes that aid be organised into three “pillars” – safer, stronger, and more prosperous.

The “safer” pillar will cover “humanitarian assistance, disaster response, global health and food security”, with aid dispensed by a new Agency for International Humanitarian Assistance (IHA). 

IHA will fall under the State Department and replace the now largely defunct USAID which dispensed around 60% of PEPFAR grants.

“IHA’s mandate would be limited to the strategic delivery of humanitarian assistance, responding to disasters, enhancing global health security (including a modified PEPFAR) and promoting international food security,” according to the document.

‘Not philanthropic’

The blueprint has emerged two-thirds of the way through the Trump-imposed 90-day “pause” on all foreign investment excluding “lifesaving humanitarian aid” – although most of that has stopped too because there are no USAID employees to dispense resources.

It stresses that US aid “should not be philanthropic in nature, but must advance our direct national security, strategic and commercial interests”.

IHA’s success will be measured by “concrete metrics: lives saved, outbreaks of infectious disease contained, pandemics prevented, famines averted and measurable increases in positive perception of the United States in emerging markets”.

The reorganisation of aid will require Congress to amend the Foreign Affairs Reform and Restructuring Act of 1998, the Foreign Assistance Act, the Pay Act and provisions of the annual Appropriations Acts.

Lack of domestic funding

The blueprint notes that “leaders of some countries are simply not committed enough to the progress of their own people to merit or justify any significant commitment of US taxpayers’ resources” but that some assistance activities “disincentivize host country investments and reforms”.

Only two of the 55 African member states – Botswana and Rwanda – spend 15% of their budgets on health, yet this is something African states pledged to do back in 2001 in the Abuja Declaration.

Dr Jean Kaseya, who heads the Africa Centres for Disease Control and Prevention (Africa CDC), told a media briefing last week that some African countries relied on “external assistance” for 80% of their HIV and malaria responses.

“Overnight, everything is gone,” Kaseya said, adding that 30% of Africa’s health expenditure comes from official development assistance (ODA), and there had been a 70% cut in ODA this year from $81 billion to $25 billion.

Kaseya will be in Washington this week to lobby for the resumption of aid, and plans to meet members of the Trump administration, PEPFAR officials and Members of Congress in a bid to restore US aid.

However, he said that there were also urgent continental efforts to get more domestic resources to fill the huge gaps left by the termination of USAID grants.

Running out of medicine

Haiti, Kenya, Lesotho, South Sudan, Burkina Faso, Nigeria and Ukraine are likely to run out of antiretroviral (ARV) medicine for HIV within the next few weeks and months as a result of USAID cuts, according to the World Health Organisation (WHO).

In Haiti, antiretroviral medicines were recently included on a special humanitarian flight to avoid a stockout, according to the Joint UN Agency on HIV/AIDS (UNAIDS)

The impact of the 90-day pause on foreign aid programs may lead to 100,000 additional HIV-related deaths this year and cause more than 135,000 babies to be born with HIV infections that could have been prevented with medications that block mother-to-child transmission, according to an estimate by researchers Khai Hoan Tram, Jirair Ratevosian and Chris Beyrer.

However, if  US assistance for HIV is not restored after the pause in April, and it is not replaced by other funding, “there will be an additional 6.3 million AIDS-related deaths in the next four years”, UNAIDS head Winnie Byanyima told reporters in Geneva this week.

UNAIDS itself may not survive as it was informed on 27 February that the US was stopping all aid to the agency with immediate effect.

Update on the status of UNAIDS agreement with the U.S. Government/USAIDhttps://t.co/6ytlfxhhoC pic.twitter.com/6o6Fn88Ujg

— UNAIDS Global (@UNAIDS) February 28, 2025

Research on an HIV vaccine, a study on long-acting pre-exposure prophylaxis and a large tuberculosis research study in South Africa have come to a halt due to US funding cuts.

As HIV is a fast-mutating virus, treatment comprises a combination of three different drugs (often combined in a single pill) that target different stages of the HIV lifecycle to stop it from making new viruses.

When people stop ARVs, their immune systems weaken and they are susceptible to all kinds of infectious diseases, with tuberculosis being the most common. They also have a high risk of developing drug-resistant HIV which is far harder to treat. In addition, as their viral loads increase they are more likely to pass the virus on to others.

However, many people in the HIV sector agree that governments need to take more ownership of their HIV response. 

Ratevosian, who is a former PEPFAR chief-of-staff, Beyrer and four other Duke University colleagues have written a policy proposal that would see countries achieving 50% co-financing for HIV within five years.

A key aspect of their proposal is that funding should move to places where the epidemic is getting worse and scale up HIV prevention by rolling out the long-acting pre-exposure prophylaxis (PrEP) injectable lenacapavir to five million most at-risk people.

Dismal prospects for PEPFAR

But influential conservatives have long sought to curtail PEPFAR.  The Heritage Foundation, which authored the conservative Project 2025 blueprint for Trump’s administration, argued in 2023 that PEPFAR should be “restructured as a development rather than an emergency assistance program”.

Except in cases of rape or maternal transmission, HIV/AIDS is “primarily a lifestyle disease (like those caused by tobacco) and as such should be suppressed through education, moral suasion, and legal sanctions,” according to the foundation.

It also claimed that “as with any venereal disease, education and abstinence could end the AIDS epidemic” – although this approach has failed miserably in both the US and Africa.

While PEPFAR projects can continue – in theory – as long as congressional appropriations (funding) are available, a much scaled-down version is likely to emerge tha may well follow the Heritage Foundation’s proposals.

Image Credits: PEPFAR, US State Department.